HomeMy WebLinkAboutrquests for information � OROHO ADMS�I2S2`R�TSYE OFFS�ES •
�TFaRMATION D=SdDATA PR CTSCES ACT
• � �Sh'2v'ESOTA GO .
• gpQUES��K NOTE= " '
g_au.est Frequency - P�ivate Data oa individuals. ��e= th�
A. n
have been supplied the data and uf fQ es�fIIonz.:nsethe e�fter �
azta ne�d not be disclosed to y
. � . .unless �'a di.spute vr ac�ion is -pendiva or additioaal data -on
.� you .has� beea. co1lectea. . _
y ouu may be reauired to pay��zCtu�Z �COS�s in �aking;
B zhe co�ies o� in=orrsation
certifying and/or co��iling
=equested. 12 • '
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Date of Requests _
� N�e= �� �� � ��., •
quester
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Descript�-on of �-f°�a��II R��esteds.
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� Recruester' s Signa�.�.e:
BELOW SNF ^}
ORMATION TO BE FII,I�E� IN BY DEPARg=''x� O�'Y
D ep ar`.�ent: _�%�f�+-�-�^'
Hand.led Fg= l��`°`-'
Mail. phone
gec�uest Type= __In perso_^. -- —
R�eS`ed By= —Subjec� of Data
Not Su:o3ect oi Dzt�
� �u:Dl.ic _ private
�fo�a�on Requested is Classified: —
public
Na�-�ublic _=rotected Nan--
Conf idential — . . � � � _ � Part
Denied � Fnnroved n_
Rea'aest is: �, Aooroved — — .
g�* arks�Ccjarme�.ts: �� "� .
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���orizea Sig�t = S
X Total Due „
Fees:• ., e5 Ftate per Page .
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ORONO AD�iTNIS�RATNE ��=�S � g� �.� � ,
I3�TE'ORMATION DSSCLOSIIRE REQUEST
. MSNNgSaTA Ga DATA PR�CTICES ACT
• gEQIIEST�F{ NOTE: .
A. gequest Freque:�c� - Private Data on individuals. Afte= you
have been supplied the data and informed of its �eaning, the
data need not be disclosed to yendi q or ada t onaledatat-on
.unless .a dispute or ac�ion is p
you .has been collected.
g, you may be reauired to pay actual costs in making,
certifying and/or compiling the co�ies o= in=ormation
requested. -
Date of Request:
,� � r � � � G �
Requester Name= �'� �
� � � . City: Q ru � d
Address: �� � ��J���- �-�
Z ip: S�3 � � - . �.� , -� ��. �..�..,,�
H�e Phane- � I 2 - y-�3 - z 3 8�J- Busines s: �- ; �� � u �
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Description of Informats.on Re�ested:
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Req'uester'. s Signature:
BELOW INFORMATION TO BE FII�I,ED IN BY DEF'ART�NT ONZY
Handle:d By':
Depar-tinent=
Mail. Phone
gec�uest Type= _In Pe'-'son —
ested B Subjec= o= Data Nc�t Sub�ect o= Data
gequ Y= `
�u'r�1.ic Private
I�o�cation Requested is Classified: —
Confidential
Non-?ubZ�� =rot:ected Non-Public
Aporoved Denied Aoproved in_Part
gequest is: — — -
Remarks/Co�m.ents:
ture: n ��`e .� �C� '
Anthorized Signa � v
_ $
Fees:� X er Fa e `.:otal Due ..
No. of Pages Rate p 5 ..